Healthcare System Models

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Transcript of Healthcare System Models

Four basic healthcare modelsOral Healthcare SystemsWhich model is best?Beveridge modelOral healthcare models in EuropeEconomic, social, and demographic climate in Europe has changeIncrease in average life expectanciesDecline in the fertility rateLed to an extension of non-employment and dependency periodsMore expensive medical services and technology

Social insurance contributors must support an increasing number of people who no longer contributeThe Bismarck system did not envision thisThe Beveridge system is also under financial pressureFinancing of the healthcare system must compete for tax allocation with other policy areas

Example of convergenceFrance (Bismarck)Imposed broad-ranging tax to finance their healthcare system in 1997 Contribution sociale generaliseeThe provision of oral healthcare often operates outside the general healthcare system and the role of private services is more significant.Example: ItalyPrivate oral healthcare system, but a public NHS for general healthcareHealthcare system modelsMeasuring oral health complicatedThere is no general, standardized measureLike quality-adjusted life year (QALY) used for general healthThe decayed, missing, and filled teeth (DMFT) index in 12-year old children is a proxy for the dental health of childrenWorkforceMost dental care provided by independent dentists in contract with the NHSContract regulates prices and treatment profiles, average income, and pensionsGrowing proportion of oral healthcare is being provided outside the NHS under private contractsAuxiliariesTeam dentistry plays an increasing role in the provision of care with dental hygienists, therapists, and clinical dental techniciansEach of the four countries within the U.K. has a national CDOEach nation’s healthcare system is a reflection of its:HistoryPoliticsEconomyNational valuesWhile all systems vary to some degree, they all share common principles.

These organizational principles are rooted in four basic healthcare models.BismarckHistoryNamed for the Prussian Chancellor Otto von BismarckInvented the welfare state as part of the unification of Germany in the 19th centuryIntroduced statutory health insurance in 1883CountriesGermany, France, Belgium, the Netherlands, Japan, Switzerland, (Latin America)BeveridgeMixed ModelOut-of-Pocket ModelHistoryNamed after William BeveridgeSocial reformer who designed Britain’s National Health Service (NHS) in the 1940sCharacteristicsSingle-payer systemIncludes the entire populationFinanceHealthcare is provided and financed by the governmentThrough tax paymentsMedical treatment is a public serviceThere are no medical billsLow costs per capitaThe government, as the sole payer, controls what doctors can do and what they can chargeWorkforceSome doctors are public (government) employeesOthers are private doctors who collect their fees from the governmentMany (but not all) hospitals and clinics are owned by the governmentSocial health insuranceNational health service"Beveridge" Tax"Bismarck"CharacteristicsHas elements of both Beveridge and BismarckFinancePayment comes from a government-run insurance program that every citizen pays intoSimpler administrative costsNo need for marketing, no financial motive to deny claims, and no profitSingle payer has considerable market power to negotiate lower prices (e.g., pharmaceutical prices)Control costs by limiting the medical services they will pay for, or by making patients wait to be treatedWorkforceProviders are privateNational health insuranceCharacteristicsOnly developed, industrialized countries have established healthcare systemsMost nations are too poor and too disorganized to provide any kind of mass medical careMost medical care is paid for by the patient, out-of-pocketNo insurance or government planBeveridge or BismarckBismarck modelCharacterized by significant government involvementGovernment has central role in guidance and supervisionCharacteristicsCombines elements of both Bismarck and Beveridge modelsEastern European model (in transition)Heterogeneous groupCharacterized by universal sickness insuranceOral healthcare is financed through compulsory social insuranceInsurance system is subject to close regulation by the governmentFinanceStatutory sickness insurance that reimburses some or all of the costs of dental careAgreements cover most restorative dental careFinanced by employers and employeesNational or regional sickness funds negotiate with dental associates about feesWorkforceDentist working independently as private practitionersVery small public sectorClinical auxiliaries rarely usedNo appointed dentist as a national Chief Dental Officer (CDO)CountriesMost central European countriesAustria, Belgium, France, Germany, and LuxembourgFinanceFinance care through general taxationSome salaried public dental services located in community and hospital clinicsFree care for children and subsidized care for adultsCountriesU.K. (England, Northern Ireland, Scotland and Wales)Nordic modelFinanceGeneral or local taxationPrivate sector subsidized through public health insuranceWorkforceA well-developed salaried serviceAuxiliariesWidespread use of clinical auxiliariesDental team is well-developed Some aspects of oral healthcare are provided by dental hygienists and clinical dental techniciansNationally appointed CDOsCountriesDenmark, Finland, Norway, SwedenException: Iceland has no public dental serviceSouthern European model(mixed systems)WorkforceSome limited clinical auxiliariesDental hygienists (except in Greece)Government appointed CDOsCountriesItaly, Portugal, Spain(Greece, Cyprus and Malta)CharacteristicsThere used to be free public oral healthcareSince political changes in 1989, public sector provision has been reducedWorkforcePastDentists were salaried public employees Oral health facilities were publicly ownedDistribution of personnel, clinics, treatments and materials was plannedPresentIncreasing privatizationDental hygienists work in these countriesNationally appointed CDOsCountriesCzech Republic, Estonia, Hungary, Latvia, Lithuania, Poland, Slovakia, and SloveniaHybrid systemsInclude a mixture of elements from a few models

CountriesIceland, Ireland, and the Netherlands

Iceland and the NetherlandsDental professionals are privateIrelandPublic/private mixCharacteristicsSickness funds (insurers)Multi-payer modelInsurance plans cover everyone, and do not make a profitFinanceFinanced jointly by employers and employees through payroll deductionWorkforceDoctors and hospitals are mostly privateAnalogy in U.S. systemWorking American who get employer-sponsored insuranceMedicaidSickness & Pepto-"Bismarck"Analogy in U.S. systemVeteran AffairsCountriesU.K., Spain, most of Scandinavia, New Zealand, Hong Kong, CubaCountriesCanada, Taiwan, South KoreaAnalogy in U.S. systemMedicareAnalogy in U.S. systemThe 50 million Americans without health insuranceCountriesMost of Africa, India, China, most of South AmericaNo country follows either of the two systems in its pure form and the deviations among individual benefits can be significantConvergence of the two systems has occurredFinancePrivate provision and finance of oral healthcare Some public services are available free to children and to treat emergenciesFunded from local or regional taxationFinanceThe majority of oral healthcare is now provided in the private sectorThe oral healthcare system models modulate the relationship between oral health and the oral health systemBy means of funding, and increasing or decreasing access to dental professionalsBut many factors come into playSome conclusions Council of European Chief Dental Officers (CECDO) database

CountriesThe former communist countries of Eastern Europe are the poorest and have the highest (worst) DMFT scoresThough there has been great improvementNordic countries have the best outcomes

Dental workforceNo significant difference among oral healthcare models and the proportion of human resourcesNo correlation between DMFT and the availability of dental healthcare professionalsSo what does influence oral health (lower DMFT in 12-year old children)?The significant parameters: Educational levelTotal healthcare expenditureIncome (GNP per capita) In part because costs of dental treatment vary in accordance with differences in GNP per capitaBut there is no difference in average expenditure among models of oral healthcare systemsTo be continued . . .Final thoughtsGeneral vs. oral healthcareGeneral healthcareBismarck systems are ranked higher than single-payer Beveridge systemsOral healthcareThe Nordic model along with the Beveridge-Hybrid model have a lower DMFT index than other models (e.g., Bismarck)